|Year : 2012 | Volume
| Issue : 2 | Page : 118-121
Tuberculosis lymphadenitis presenting a diagnostic dilemma
Divya Shetty1, Devi C Shetty2, Harkanwal P Singh3, Palak Aggarwal2
1 Department of Orthodontics, ITS Dental College, Ghaziabad, Uttar Pradesh, India
2 Department of Oral Pathology and Microbiology, ITS Dental College, Ghaziabad, Uttar Pradesh, India
3 Department of Oral Pathology and Microbiology, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana, India
|Date of Web Publication||27-Sep-2012|
Harkanwal P Singh
Department of Oral Pathology and Microbiology, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana
Source of Support: None, Conflict of Interest: None
Tuberculosis (TB) is a prevalent systemic bacterial infectious disease usually caused by Mycobacterium tuberculosis. It is estimated that approximately 8 million people develop TB each year, and 3 million people die of complications associated with the disease. In this article, we report a case of a 22-year-old female patient with a painless swelling in her submental region. She was diagnosed with tuberculous lymphadenitis. Tuberculous lymphadenitis, when occurring in the cervical region, continues to be a common cause of extrapulmonary TB. TB is a recognized occupational risk for dentists, as they work in close proximity to the nasal and oral cavities of patients, with the possible generation of potentially infectious sprays during routine operative procedures.
Keywords: Granuloma, lymphadenitis, pulmonary, tuberculosis
|How to cite this article:|
Shetty D, Shetty DC, Singh HP, Aggarwal P. Tuberculosis lymphadenitis presenting a diagnostic dilemma. Int J Health Allied Sci 2012;1:118-21
|How to cite this URL:|
Shetty D, Shetty DC, Singh HP, Aggarwal P. Tuberculosis lymphadenitis presenting a diagnostic dilemma. Int J Health Allied Sci [serial online] 2012 [cited 2020 Jan 25];1:118-21. Available from: http://www.ijhas.in/text.asp?2012/1/2/118/101718
| Introduction|| |
TB has been a worldwide health problem for centuries and it is a chronic infectious granulomatous disease caused by bacteria. It usually is acquired by inhaling droplets contaminated by Mycobacterium tuberculosis; however, M. avium, M. bovis, M. kansasii, and M. scrofulaceum have also been implicated as causes.  Local factor that may facilitate the invasion of oral mucosa includes poor oral hygiene, leukoplakia, local trauma, irritation by clove chewing, etc. 
It has also been shown that the presence of M. tuberculosis in oral samples is almost universal in patients with tuberculosis.  Viable acid-fast micro-organisms may be recovered from swabs or washings of oral cavities of tuberculosis patient. Furthermost, aerosol transmission of bacteria can occur during dental treatment such as ultrasonic scaling and use of air-turbine headpieces. Thus, the diagnosis of oral tuberculosis is imperative in a dental set-up. 
Tuberculosis of oral cavity is an extremely rare development. Initial lesions are usually pulmonary although an increase in extrapulmonary TB has been reported in recent years. These frequently involve the head and neck, with the most common presentation being a mass in the cervical region.  Tuberculosis of the lymph node (tuberculous lymphadenitis) is the most common form of extrapulmonary tuberculosis. Its involvement of the cervical lymph nodes has been known for centuries as scrofula or the King's Evil.  This article reports a case of 22-year-old female with tuberculous lymphadenitis.
| Case Report|| |
A 22-year-old female reported with the chief complaint of painless swelling in submental region since 4-5 months [Figure 1]. The patient was apparently asymptomatic 5 months back, when she noticed a painless swelling in the submental region which gradually increased in size with no associated symptoms. Pain and discharge was absent.
|Figure 1: Extra oral examination revealed a swelling in the submental region|
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General physical examination revealed that the patient was moderately built and nourished. All the vital signs were within normal limits. Extra oral examination revealed a swelling in the submental region which was ovoid in shape, pale yellow in colour, measuring approximately 2.5 × 3.0 cm in diameter. On palpation, margins were well defined, non-indurated soft in consistency and non-tender. None of the lymph nodes were palpable.
A provisional diagnosis of tuberculous lymphadenitis was made. Differential diagnosis of right submandibular sialadenitis, right submandibular gland calcification was considered. A panoramic radiograph was carried out and it did not reveal odontogenic origin in relation to the swelling. A Mantoux test was positive. No abnormality was detected in chest radiograph. A complete hemogram was performed but it did not revealed any abnormal findings.
An excisional biopsy was performed and the tissue was submitted to the department of Oral pathology. Soft tissue specimen round to oval, creamish yellow in colour, measuring 2 × 1.5 × 1 cm with well-defined margins was submitted [Figure 2] and [Figure 3].
|Figure 2: Soft tissue specimen round to oval, creamish yellow in colour with well defined margins|
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On microscopic examination, the H and E section studied showed a well-encapsulated lymph node with abundant lymphocyte aggregates surrounding numerous granulomas [Figure 4]. Clusters of ovoid to spindle-shaped epitheloid cells are seen with foci of central casseous necrosis. Around these epitheloid cells, organized collagen fibres intermingled with fibroblastic population is noticed with langhans giant cells. An intermediate area between these granulomas shows numerous lymphocytes and plasma cells along with macrophages. At numerous places in the capsule, the presence of langhans giant cells is noticed [Figure 5], [Figure 6].
|Figure 4: Photomicrograph showing well encapsulated lymph node with abundant lymphocyte aggregates surrounding numerous granulomas. (H and E; ×4)|
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|Figure 5: Photomicrograph showing presence of langhans giant cells in the capsule admixed with abundant lymphocyte aggregates and plasma cells along with macrophages, (H and E, ×10)|
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|Figure 6: Photomicrograph showing presence of langhans giant cells in the capsule admixed with abundant lymphocyte aggregates, (H and E, ×40)|
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Evaluating the clinical and histopathological findings, the confirmatory diagnosis of tuberculous lymphadenitis was achieved. The patient was referred to the TB hospital for further treatment. Treatment consisted of anti-TB drugs for a period of 6 months. No complications occurred and no further surgery was required.
| Discussion|| |
Tuberculous adenitis is a common cause of lymphadenopathy in areas where TB is endemic. It is one of the most common of all extra-pulmonary tuberculosis, second only to tuberculous pleurisy.  The incidence of extrapulmonary TB is 5.4% in the United States. TB lymphadenitis comprises 30-50% of these cases. The most common site is cervical lymph nodes. This is referred to as scrofula.  In developed countries, tuberculosis is implicated in as few as 1.6% of patients with lymphadenopathy but in developing countries almost two third of the cases of lymphadenopathy are due to tuberculosis. 
The involvement of cervical lymph nodes in tuberculosis could be the result of the tonsils and adenoids providing an easy portal of entry for inhaled mycobacteria. However, it could also result from lymphatic spread or by hematogenous dissemination from an original focus in the lung. About 30% of reported lymphatic tuberculosis has concomitant pulmonary lesions. Some suggests that tuberculous cervical lymphadenitis is the lymph node component of primary complex of the oral cavity where such structures as gums, tongue, and buccal mucosa can be infected and subsequently healed without being detected.  Tuberculous involvement of oral cavity is an extremely rare development, even in populations with high incidence of the pulmonary disease. Saliva is believed to have a protective effect, which may explain the paucity of tuberculous oral lesions, despite the large numbers of bacilli contacting the oral cavity mucosa in a typical case of pulmonary tuberculosis. Other factors that attribute to relative resistance of oral cavity for tuberculosis are the presence of saprophytes, resistance of striated muscles to bacterial invasion, and thickness of protective epithelial covering. 
The predominance of TB adenitis in young age groups and in females has been well documented by various authors,  in contrast to pulmonary tuberculosis which is more common in males and in the older age group. The reason for this is not clearly understood however the underprivileged condition of women in rural Indian society may be a factor. 
The classical paper by Wallgren postulated that different manifestations of tuberculosis depend on the infected person's age, his resistance, and more importantly, the age of the tuberculous infection. Primary TB and haematogenous spread occur soon after infection in young people.  Tuberculosis should be strongly suspected in a young patient presenting with peripheral lymphadenopathy, with prolonged duration of illness, and involvement of cervical glands with multiple and matted appearance. 
The Ziehl Neilsen stain for identification of acid-fast bacilli can be used to increase the diagnostic accurate tuberculous lymphadenitis. Cervical lymphadenitis remains a diagnostic and therapeutic challenge because it mimics other pathologic processes and yields inconsistent physical and laboratory findings. Granulomas can be present in a variety of conditions causing lymphadenopathy. Diseases including sarcoidosis, carcinoma, lymphoma or sarcoma, viral or bacterial adenitis, fungal disease, toxoplasmosis, cat scratch fever, collagen vascular diseases, and diseases of the reticuloendothelial system can present the same cytology or histopathology as tuberculous lymphadenitis.  In the present case, submental swelling was noticed clinically and histopathologically numerous granulomas along with giant cells are seen. Thus, a confirmatory diagnosis of tuberculosis was given.
A high index of suspicion is needed for the diagnosis of mycobacterial cervical lymphadenitis. Atypical mycobacteria have also been incriminated in producing enlarged cervical lymph nodes. It is important to differentiate tuberculosis from non-tuberculous mycobacterium cervical lymphadenitis because their treatment protocols are different. 
Early diagnosis is the cornerstone of tuberculosis control strategies. Treatment for tuberculous lymphadenitis is essentially the same as for pulmonary tuberculosis, though the duration should as a rule is at least one and half years. This is because the bacilli in the lymphatic tissue where the oxygen tension is low are usually the slow metabolizing organisms or persisters. Rifampicin-containing short course regimen has been found to be effective if given for 9 months. The effected lymph nodes usually regress the treatment. With the advent of modern effective anti-tubercular drugs, suppurating tuberculous lymphadenitis can be safely drained without the fear of developing chronic discharging sinuses.  But the medical personnel are also at risk, as illustrated by the case of a physician who developed naso-labial infection after mouth-to-mouth resuscitation on a tuberculosis patient. Practicing infection control techniques can limit the threat posed to medical personel. 
| Acknowledgment|| |
The Author would like to thank the patient for providing consent to use her photograph in this article.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]